How Are We Caring for Our Mentally Ill Post Deinstitutionalization?

(Article published in Street Speech by the Columbus Coalition for the Homeless) 

What is deinstitutionalization? It was a political/social/economic movement which began way back in the 50’s to close state hospitals where mentally ill patients were warehoused for years and released them into the community and the community mental health system.

Part of the impetus for this move came from patient advocacy groups and the civil liberties movement who wanted to end the neglect and abuse of patients in state facilities around the country which were notorious for poor living conditions, lack of hygiene and overcrowding.

Another reason was economic. States thought it would be less expensive to take care of the mentally ill in outpatient treatment, especially with the advent of new antipsychotic drugs which came on the market in the 50’s and 60’s.

A further impetus came when President Kennedy passed the Community Mental Health Centers Act in 1965. It called for a 50% reduction in the number of state psychiatric patients. This shift away from custodial care to outpatient care became known as “deinstitutionalization.”

Communities were expected to put in place a whole range of services including supervised group homes, walk-in clinics where medication could be administered, and enough case workers to oversee patients’ compliance with their treatment plans. As the economy got worse however, many of these programs were discontinued – some were never implemented. It was a good idea which never got the necessary funding and left thousands of mentally ill without any support at all.

Even when communities provided clinics and screening centers, the caseloads of social works were too big to allow the degree of supervision and evaluation needed. John Hughes, the Workforce Development Manager for the Columbus Coalition for the Homeless, spent 30 years working with at-risk people with substance abuse, mental health and housing issues. He says “a caseload can be as high as 70-75, or higher, for a social worker in the field.”

A small number of people who are chronically mentally ill need some level of supervision on a regular and consistent basis, both for their protection and the protection of the public. The average length of stay in our state hospitals today is only between ten and fourteen days. This does not meet the needs of our most seriously ill patients. Hospital stays on acute care psychiatric units in our general hospitals are even shorter.

Patients are then discharged back into the community with a one to two week supply of meds and told to follow-up with their local mental health agency. This requires patients to have the insight to realize they need to stay on their medication, and to take it regularly without supervision, and the ability to be proactive with phone calls and appointments to keep themselves supplied with their medication. Sadly this is often not the case and it is one reason why so many mentally ill people “fall through the cracks” in our system.

Without a support system in place many suffering from mental illness become homeless. Food kitchens thankfully are available to feed the homeless in Columbus. Most are run by charitable organizations and the homeless are grateful for them. But housing is another matter. Our shelters have long waiting lists to get in and as cold weather creeps up on us this will become an even greater problem than it already is.

Barrie Currie, a homeless paper vendor at the Columbus Coalition for the Homeless said, “People go to shelter for many different reasons- most of all because they’re supposed to be safe. However nothing could be further from the truth! There is a lot of violence in places like these.” The mentally ill are especially vulnerable, both in shelters and on the street.

In a recent segment on 60 Minutes this past fall, the lack of adequate mental health services was discussed in light of the recent rise in mass shootings. Dr. E. Fuller Torrey, one of the country’s leading psychiatrists, said: “These were preventable tragedies, symptoms of a failed mental health system that’s prohibited from intervening until a judge determines that someone presents an imminent danger to themselves or others. The consequence is a society that’s neglected millions of seriously ill people hidden in plain sight on the streets of our cities, or locked away in our prisons and jails.”

Most of us would be shocked to learn how many mentally ill people are in our jails and prisons. According to Human Rights Watch somewhere between two and three hundred thousand men and women in U.S. prisons suffer from a mental disorder. Using our jails instead of state hospitals to incarcerate those with mental illness who are considered unmanageable or a danger to others on our streets has been referred to by some as a form of re-institutionalization. Ironically, the country’s three largest mental facilities now are the Los Angeles County Jail, New York City’s Riker’s Island and Cook County Jail in Chicago. It seems we have moved from warehousing patients in state mental institutions to warehousing them in jails instead.

The Cook County sheriff, Tom Dart, says, “The prisons and jails have become the new asylums.”

Dart went on to describe how mentally ill prisoners are put into a tiny, confined space, sometimes with another mentally ill cellmate who may or may not be violent. The confinement and lack of stimuli can cause inmates mental state to deteriorate further or exacerbate existing symptoms like depression and psychosis.

“Not treating people with mental illness is bad enough,” Dart said. “But treating them like criminals? What have we become?”

How do the mentally ill fare in Ohio jails? Ohio is now considered a model for the country for providing mental health care behind bars. Following a 1993 class action lawsuit claiming that the care of prisoners with serious mental illness was constitutionally inadequate, sweeping reforms were instituted in the state’s prison system. These included the establishment of Residual Treatment Units (RTU’s) to provide care and supervision for inmates who required special housing separate from the general prison population. Individualized treatment plans are developed for each inmate and in extreme cases they may be moved to the Oakwood Correctional facility for short term stabilization. Ohio is one of only twelve states that has a prison psychiatric hospital. At Oakwood inmates are treated like patients rather than prisoners.

Ohio should be proud of the efforts it has made to provide treatment for mentally ill inmates but our goal must be to provide psychiatric care for the mentally ill in our communities so they don’t end up in prison in the first place.

One such effort to do this is provided by Netcare, serving Franklin, Jackson, Delaware, Fairfield, Hocking, Ross, Fayette, Licking, Madison, Pickaway, and Union Counties. It provides assessment services for the courts to determine the proper disposition for arrestees. Offenders with a mental health disorder are referred for supervised treatment rather than incarceration.

Similarly, Sheriff Drew Alexander, of Ohio’s Summit County took action last year by implementing a new policy which requires violent, mentally ill arrestees to be treated at a hospital or mental health clinic before being referred to the county jail.

“We’re not going to be a dumping ground anymore for these people,” Sheriff Alexander said.

Once released from our jails or prisons, many mentally ill face the same challenges as those discharged from psychiatric hospitals. Homelessness is often one of the main reasons for the high recidivism rate among ex-felons.

Reggie Wilkinson, Fmr. Director of the Ohio Department of Corrections said, “Any person released from prison who does not have a pretty good support system, including stable housing, will have a difficult time staying out of prison. Most stop taking their medication fairly soon after being returned to the community.”

Bridgeview Manor, a residential facility for the severely mentally ill in Ashtabula, Ohio is home to sixteen adult men, most of whom are schizophrenic. It is a residential home in Ohio that provides a place to live and on-site mental health treatment and case management for both indigent clients and ex-felons. More such facilities are needed for the thousands of inmates awaiting release back into the community.

Clearly this situation will continue to be a problem until funding is made available to provide adequate community mental health services. Sadly it appears that this is a population that people don’t care about and so the resources are not there in our communities to care for them humanely.